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self_made_human  Grippy socks, grippy box  1mo ago (open.substack.com)   1589 thread views

Escaping the Jungles of Norwood: A Rationalist’s Guide to Male Pattern Baldness

open.substack.com

Out of enlightened self-interest, I did a deep dive into the topic of male pattern baldness, and after freshening up on my rather rusty Bayes', I decided that I'd gone to enough effort to justify a proper blog post. Here you go.

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I agree that finasteride is treated unfairly. Even if you're in the unlucky 1-2% that gets significant side effects, they usually wear off in weeks or months from cessation.

Thanks for reading, and good luck keeping your hair while you still need it!

A British friend of mine takes Finasteride and swears by it. I asked my (urologist) doctor about it once in the dark days when I was fannying about worried about my hairline, and he looked at me and said "You will develop man-boobs." (Urologist due to BPH, but they can also prescribe it--though he said he was unwilling to).

Anyway since then I've both calmed down and lost much interest in Finasteride. I believe you mentioned minoxidil, which is basically Rogaine right? But has no hormonal component that I know of. (I write all this before reading your deepdive but I will from now.)

Minoxidil alone will not do much. You'll keep losing hair, fin is the most important intervention, pretty safe. Some people do experience heart issues when they ingest minoxidil orally. Topical use is safe.

At times, I am dismayed by other doctors' ignorance regarding base rates, relative risks, and their attitude towards pontification without additional qualifiers towards their patients. Of course, we're only human, fallible, and working with a patient population that isn't necessarily sophisticated enough to follow such caveats. I'm guilty of this myself, even though I strive to be better.

As far as I'm aware, there's no reason to think that finasteride must cause BPH and man boobs in your case. It increases the risk, but that's a quantifiable increase in probability and far from a certainty.

AFAIK, Rogaine is just a formulation of basic bitch minoxidil. It's inoffensive, doesn't have very strong effects, but when applied topically, doesn't have significant drawbacks either. We don't know for a fact how minoxidil even works, but the prevailing hypothesis is that it improves blood flow to the local tissues near where it's administered. This ?somehow increases hair growth.

Even if you're in the unlucky 1-2% that gets significant side effects, they usually wear off in weeks or months from cessation.

Papers on that say something completely different.

1.4% (167 men) developed persistent erectile dysfunction lasting a median of 1348 days.

My understanding is that this is a contested finding, but even assuming the usual relative risk of ED while actively taking finasteride (~1.5x baseline), the absolute risk is not so high that you need to run away screaming. That being said, unless my hair falls out by the fistful overnight, I would personally take my chances with minoxidil first.

I am weakly agnostic on this claim, but my primary motive was to explain that the claim by this pharma professor half a decade back was hyperbole.

the absolute risk is not so high that you need to run away screaming

You suggest this ED is some sort of lizardman finding and if you examined the health database you'd find 1.5% 15-42 male are getting ED that lasts 5 years even even if they don't use finasteride?

https://cks.nice.org.uk/topics/erectile-dysfunction/background-information/prevalence/

Erectile dysfunction is a very common disorder, and the incidence and prevalence increases with age [Hackett, 2018; Muneer, 2014; EAU, 2022]. The Massachusetts Male Aging Study (MMAS) in the USA, a community-based, random sample, prospective observational study of non-institutionalized men in the Boston area, used a self-administered sexual activity questionnaire, and found [Feldman, 1994]: A self-reported overall prevalence of erectile dysfunction in 52% of men aged 40–70 years. The specific prevalence for mild, moderate, and severe cases was 17.2%, 25.2%, and 9.6% respectively. The prevalence increased with increasing age (increasing three-fold between men aged 40 and 70 years).

A large German postal survey (the 'Cologne Male Survey') of men aged 30–80 years (n = 8000) reported [Braun, 2000]: A prevalence of erectile dysfunction of 19.2%. The prevalence of erectile dysfunction increased from 2.3% at 30 years to 53.4% at 80 years of age. Expert opinion in a review article

These are not really comparable, method or cohort wise. Postal survey is probably biased towards bored old people..

Also it's strongly suggestive that on the link paper claims length of exposure to finasteride was correlated with the ED..

You too doc. Fin is the single most important intervention. I was lucky that I did not heed advice from e Alpha Males for my issue. Did not know you had a substack.

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